Provider Demographics
NPI:1659881423
Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Entity Type:Organization
Organization Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Other - Org Name:UTSW MONCRIEF MED CTR PHARMACY AT FORT WORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-633-4804
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9222
Mailing Address - Country:US
Mailing Address - Phone:469-525-5908
Mailing Address - Fax:817-882-2501
Practice Address - Street 1:600 S MAIN ST STE 1.102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2410
Practice Address - Country:US
Practice Address - Phone:817-882-2500
Practice Address - Fax:817-882-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX315863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2171740OtherPK
TXPENDINGOtherNCPDP
TXPENDINGOtherPART B
TXPENDINGOtherVENDOR DRUG PROGRAM
TXPENDINGMedicaid